December 7, 1941 Pearl Harbor.... Lots of casualties. Patient safety routine efforts primarily consist of finger on the pulse, eyes on the chest, observation of skin color. The recently released drug, thiopental, is employed. Some of the soldiers die…of anesthesia (1-3). Anesthesia-related death rate reported at 1 in 450 (2).
September 1979 – September 1981 (WAK residency time). The operating surgeon calmly notes blood’s dark. WAK’s reaction: BLOOD'S DARK!!! Dr. Todres says the first 3 things to check for with any problem in the OR is, first airway, then the airway, and finally the airway. So he checks it and finds a disconnect which somehow was not able to be heard with the esophageal stethoscope over the orthopedists’ hammers and drills. No oxygen analyzer, no disconnect alarm, no pulse oximeter, no automated blood pressure monitor; by today’s standards, no nothing, although we did have manual blood pressure cuffs, EKG machines, and the beginnings of advanced hemodynamic monitoring. WAK’s attendings were fond of saying “when I was a resident…” followed by some parable of how he managed with no monitors other than his five senses. It seemed like at least once a year at M&M there was discussion about an intraoperative death by undetected disconnect. Anesthesia death rate said to be about 1 in 10,000.
2007. Cyanosis is virtually never seen by trainees and death by disconnect is now unheard of. Gas analyzers, pulse oximetry, end-tidal CO2, easily balanced pressure monitors, idiot proof machines and more are part of the modern anesthesia tool box. Anesthesia death rate in healthy patients thought to be about one in 200,000 (4,5). Remarkable progress.
The Anesthesia Patient Safety Foundation was formed September 30, 1985, by Ellison Pierce with the help of many others. The efforts of the APSF (http://www.apsf.org/) have produced this remarkable transformation in the patient care environment which arose initially in the operating room, and now is spreading to general medical/surgical/pediatric floors, emergency departments, and intensive care units. The accomplishments of the specialty of anesthesiology in advancing patient safety have been so successful that it has been emulated by other medical specialties and the patient safety movement has morphed into a multidisciplinary national safety patient foundation (http://www.npsf.org/) which will undoubtedly address many of the patient safety issues that are now recognized as widespread outside of operating rooms. Indeed, the notion of patient safety started by these visionaries has now infected the culture of medicine and it is now the buzz word of quality improvement programs everywhere. However, there is still a remaining problem with health care practitioners following the “watch one, do one, teach one” mantra from the Flexner era and before, leading current visionaries to conceive and promulgate simulation as an educational tool to advance patient safety.
Simulation: Simulation: a situation or environment
created to allow persons to experience a representation of a real event for the
purpose of practice, learning, evaluation, testing, or to gain understanding of
systems or human actions. –definition taught at the Center for Medical
1967. Red Cross first aid classes teach a fairly
recently described new CPR method, having discarded the chest pressure-arm lift
method, the primary resuscitation method of the 50s and 60s and perhaps
before. So what did we practice our CPR on? Resusci-
Above excerpted from my intro (before the copy editors got their hands on it) to the just published
New Vistas in Patient Safety and Simulation, An Issue of Anesthesiology Clinics
3. Bennetts FE: Thiopentone anaesthesia at
4. Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70:572-7.
5. Lagasse RS: Anesthesia safety: Model or Myth? Anesthesiology 2002; 97:1609-1617.